Neurología.

2012;27(2):90—96

NEUROLOGÍA
www.elsevier.es/neurologia

ORIGINAL ARTICLE

Profile of children and adolescents with autism spectrum

disorders in an institution in Bogotá, Colombia夽
C. Talero-Gutiérrez a,∗ , M. Rodríguez a , D. De La Rosa a , G. Morales b ,
A. Vélez-Van-Meerbeke a

a
Grupo de investigación NEUROS, Línea en Neurociencia Cognitiva, Escuela de Medicina y Ciencias de la Salud, Universidad del
Rosario, Bogotá, Colombia
b
ANTHIROS, Centro de desarrollo infantil, Bogotá, Colombia

Received 14 December 2010; accepted 6 March 2011

Available online 4 May 2012

KEYWORDS Abstract
Pervasive Objective: To determine the profile of children and adolescents diagnosed with autism spec-
developmental trum disorder (ASD) in a comprehensive care centre in Bogota, Colombia.
disorder; Material and methods: A descriptive-correlational study with a sample of patients who had
Autism spectrum attended the institution from 2003 to 2009. Demographic and clinical aspects were evaluated
disorder; and a correlation between the diagnosis and severity being analysed in search for risk factors.
Autism; Results: A total of 138 patients were studied. The average age of onset was 21 months, and
Risk factors; diagnosis had been made at 45 months. There was a male predominance (6.15:1). The predom-
Neurological inant diagnosis was autistic syndrome (83%), followed by pervasive developmental disorder not
development otherwise specified (17%). There was no pathological background in the family history, during
pregnancy or during the neonatal period. Motor development during the first year was normal
but acquisition of language skills was compromised. The specific signs of ASD as regards the
disorder in itself, communication skills, spontaneous speech, verbal comprehension, attention,
imitation, use of objects, self-care and symbolic play were significantly related to the severity
of the disease.
Conclusions: Diagnosis of ASD is still delayed in our population and usually after referral from
someone other than a health professional. The most important problems were found in commu-
nication skills and relationships with peers. The study did not show significant associated risk
factors.
© 2010 Sociedad Española de Neurología. Published by Elsevier España, S.L. All rights reserved.

夽 Please cite this article as: Talero-Gutiérrez C, et al. Caracterización de niños y adolescentes con trastornos del espectro autista en

una institución de Bogotá, Colombia. Neurología. 2011;27:90—6.

∗ Corresponding author.

E-mail address: claudia.talero@urosario.edu.co (C. Talero-Gutiérrez).

2173-5808/$ – see front matter © 2010 Sociedad Española de Neurología. Published by Elsevier España, S.L. All rights reserved.
Autism spectrum children in Bogotá, Colombia 91

PALABRAS CLAVE Caracterización de niños y adolescentes con trastornos del espectro autista en una
Trastorno institución de Bogotá, Colombia
generalizado del
desarrollo; Resumen
Trastorno del Objetivo: Caracterizar la población de niños y adolescentes con diagnóstico de trastornos del
espectro autista; espectro autista (TEA) en un centro de atención integral en Bogotá Colombia.
Autismo; Material y métodos: Estudio descriptivo-correlacional, de la población de pacientes que han
Factores de riesgo; asistido al centro desde el año 2003 hasta el 2009. Se evaluaron los aspectos demográficos y
Neurodesarrollo clínicos, y se realizó una correlación entre las variables con el diagnóstico y la severidad para
la búsqueda de factores de riesgo.
Resultados: Se estudió a 138 pacientes. La edad promedio de inicio fue a los 21 meses y el
diagnóstico a los 45. Hubo predominancia masculina (6,15:1). El diagnóstico mas frecuente
fue síndrome autista (83%), seguido por trastorno generalizado del desarrollo no determinado
(17%). No se encontraron antecedentes importantes en la familia, durante el embarazo ni en
el periodo neonatal. El desarrollo motor durante el primer año fue normal mientras que el
desarrollo de la comunicación verbal se encontró comprometido. Los signos específicos de TEA
como el trastorno en referencia a sí mismo, comunicación, habla espontánea, comprensión ver-
bal, atención, imitación, utilización de objetos, autocuidado y juego simbólico se relacionaron
significativamente con la severidad del cuadro.
Conclusiones: El diagnostico de los TEA continúa siendo tardío en nuestra población y general-
mente luego de la remisión de personal ajeno a la salud. Las alteraciones más importantes se
encuentran en la comunicación y en la relación con los pares. En el estudio no se evidenciaron
factores de riesgo que pudieran estar asociados.
© 2010 Sociedad Española de Neurología. Publicado por Elsevier España, S.L. Todos los derechos
reservados.

Introduction there are no criteria for any of the other 4 ASDs because the
symptoms appear minimally or their onset is belated.3
Early detection and an appropriate intervention can mit-
According to the Diagnostic and Statistical Manual of Mental
igate the long-term deleterious effects and improve quality
Disorders of the American Psychiatric Association (DSM IV),
of life. The importance of ASD lies in their high preva-
the criteria for what are known as generalised developmen-
lence, which is between 60 and 70/10,000 inhabitants. They
tal disorders or autism spectrum disorders (ASDs) include a
are distributed according to the different types of clinical
group of medical conditions that manifest during early child-
profiles as follows4 : AD 20/10,000; PDD-NOS 30/10,000; AS
hood through involvement of developmental skills for social
6/10,000; RS 1/10,000—20,000 and childhood disintegrative
interaction and communication or by the presence of repet-
disorder 2/100,000.
itive motor behaviours, stereotypes and unusual or peculiar
In terms of incidence, developed countries present 1 new
interests. Taking into account specific characteristics, these
case per year for every 500—700 newborns. However, up to
entities have been named autistic disorder (AD), Asperger
40% of patients who received a diagnosis of ASD at some
syndrome (AS), pervasive developmental disorder-not other-
point did not have the diagnosis confirmed subsequently with
wise specified (PDD-NOS), Rett syndrome (RS) and childhood
specific tests.5 The male to female ratio is 4:1, except for RS,
disintegrative disorder (DD).1
which is more common in the female population.6 No studies
All ASDs share some of the classic symptoms of autism
could be found evaluating the epidemiology of this disorder
described by Kanner but differ in terms of severity, combi-
in Colombia or determining its presentation, demographics
nation of affected areas, course and prognosis.2 In RS and
or symptoms.
DD there is a developmental regression after a period of
This project aimed to study a population of children and
normality (5—30 months in RS and 2—10 years in DD). In
adolescents attending ANTHIROS, a reference centre for the
both disorders, a seemingly normal child loses the develop-
diagnosis and rehabilitation of patients with ASD in Bogotá,
ment achieved in motor skills, language and socialisation,
Colombia. We described their clinical features and relevant
developing some of the classic symptoms of autism. RS is
diagnostic history so as to determine the existence of risk
a rare, progressive, neurological disease in which there is
factors during the different periods of development. We also
a deceleration of brain growth. It is assumed that DD is
analysed the possible association between these and the
due to acquired neurological damage, but in many cases
presence and severity of ASD.
its aetiology is unknown. AS is defined by impairment in 2
domains of the autism triad: social interaction and stereo-
typed behaviours, peculiar interests and activities. Although
its diagnosis does not require changes in communication, Patients and methods
such constraints are often present, especially in the prag-
matics of language. The diagnosis of PDD-NOS is reserved We conducted a descriptive, observational study of a
for cases in which there are no symptoms of autism, but series of children and adolescents diagnosed with autism
92
spectrum disorder, taken from the population of children
who attended the child development institution ANTHIROS
for diagnosis and rehabilitation. We excluded all medical
records of children younger than 2 years and older than
18 years, as well as those in which it was clear that the
children suffered from severe hearing loss, metabolic disor-
ders, Gilles de la Tourette syndrome, meningitis, epileptic
encephalopathy, genetic syndromes with known cause or
mental retardation with symptoms similar to those found
in ASD.
We reviewed the medical records of all patients exam-
ined at the institution between 2003 and 2009. We recorded
those variables associated with the risk of ASD onset, as
well as those considered in the child evaluation protocol
of the institution. Among them, we recorded demographic
variables, family and personal history (prenatal, perinatal,
postnatal), motor, speech and psycho-emotional develop-
ment and behavioural variables.
We created an Excel database to store the informa-
tion according to the instrument designed previously. In
order to ensure data accuracy, we reviewed each of the
medical records to confirm the diagnosis prior to enter-
ing the information into the database. We excluded from
the study those records not having complete information
or those in which the quality of the information did not
allow for conclusive identification of the information rel-
evant to the study. We conducted a review of the database
to identify any missing data or alterations during typ-
ing.
Data for qualitative variables such as demographic, aeti-
ological, and evaluative factors and other factors were
analysed using measurements of absolute and relative fre-
quencies expressed as percentages. Quantitative variables
were expressed using measures of central tendency such as
mean and median, and dispersion variables were expressed
using range and standard deviation. For the purpose of cal-
culating the mean in the case of acquisition of development
patterns in patients who had not acquired a specific item,
we took their age in months at the time of admission to the
institution. We used the Pearson chi-square association test
and the Fisher exact probability test (expected values <5)
to assess the association between various risk factors and
the presence and severity of ASD. Likewise, we used the
Kruskal—Wallis test to evaluate the medians. Results were
considered positive when the significance level was less than
5% (P < .05). Finally, we conducted an associative model of
multivariate analysis using unconditional logistic regression
of diagnoses and clinical signs to assess the severity using
a hierarchical selection model and we assessed the multi-
collinearity among the different factors that made up the
model.
This study was classified as safe without risks according
to the standards set by the Health Ministry of Colom-
bia. In addition, we followed the recommendations of
the Helsinki Declaration of the World Medical Associa-
tion. The protocol was approved by the institution prior
to gaining access to medical histories and was also
approved by the research ethics committee at Univer-
sidad del Rosario. All data were handled through the
clinical history ID number, with no mention to names of
patients or their families in order to preserve confidential-
ity.
C. Talero-Gutiérrez et al.
Table 1 Age.
Age (months) Mean Minimum Maximum Mode Median
Initial 20.6 0.5 84 24 18
Diagnosis 45.5 12 240 36 36
Admission to 64.2 20 254.5 29 52
centre
Results
We evaluated the medical records of 138 patients, 52% of
whom were from the city of Bogotá and the rest from other
cities throughout the country. The mean age of onset accord-
ing to parents was 21 months, but the diagnosis took place
at 45 months (Table 1). There was male predominance, with
119 males and 19 females (6.15:1). Patients were admit-
ted to the institution with a mean age of 64 months, mostly
referred by people outside the health or education services
(Fig. 1).
Considering the DSM IV criteria, the diagnosis established
through evaluation by an interdisciplinary team corre-
sponded to autistic syndrome in 109 cases (80%), followed
by PDD-NOS in 22 (17%). As expected, the number of chil-
dren diagnosed with childhood disintegrative disorder or AS
was very low and there were no girls with Rett syndrome.
Children were classified as follows, according to severity
as assessed by the childhood autism rating scale (CARS)7 :
- Not autistic (score 15—29): 2.2%.
- Moderately abnormal (score 30—36): 45.6%.
- Severely autistic (score 37—60): 52.2%.
These data are significantly related to the type of diagno-
sis, being more severe in children with AS, followed by those
who presented childhood disintegrative disorder (P = .000).
The mean age of the mother was 30 (16—43) years and
that of the father was 33 (19—58) years. No consanguinity
was found in 84% of them. No significant family history during
pregnancy or the neonatal period was observed, except for
some family members with conditions that could somehow
be related to ASD. A total of 51% of cases were born by cae-
sarean section and 20% of premature infants were identified
(Table 2). Perinatal complications, specifically acute foetal
distress, took place in only 12% and severity was not greater
since neither neonatal resuscitation nor neonatal intensive
care were required. No neurological disorders were reported
in the newborn. Weight and size were appropriate in 70% of
children.
Motor development during the first year was generally
normal, but an association was found between late onset
of sitting and severity of ASD (P = .000). With regard to
the development of verbal expression (babbling, words and
phrases), the acquisition was generally above the expected
range for the age and a significant number of children who
had not acquired verbal communication skills were observed
at the time of admission at the institution (Table 3).
The areas of self-reference signs, communication
disorders, spontaneous speech, verbal comprehension,
attention, imitation, use of objects, self-care and play were
Autism spectrum children in Bogotá, Colombia 93

45%

40% 39%

35%

30%

25% 22%
20%
20%

15%
11%
10%
6%
5% 2%

0%
Physician Psychologist OT Kindergarten Other No data
teacher

Other: individuals without training in health or education such as parents, caretakers, friends, etc.

Figure 1 Source of referral of patients to the institution. OT: occupational therapist.

using the following factors: type of diagnosis (AS and DD),

Table 2 Positive precedents in the clinical history.
lack of sustained attention, lack of joint attention, absence
Family history of reference to self and dependence for basic self-care activ-
ASD 4% ities. We found the existence of multicollinearity between
Delay in psychomotor development 2% the various factors specific to ASD, so that absence of
Cognitive disability 9% communication, spontaneous speech and verbal compre-
Alterations in speech 22% hension could have also been included within the model
Alterations in learning 7% (Table 5).
Epileptic crises 5%
Psychiatric pathology 10%
Obstetric history Discussion
Taking of medication 15%
Risk of abortion 9% ASDs are characterised by persistent disabilities in several
Breakage of membranes 1% areas of development: inability in reciprocal social interac-
Placenta praevia 1% tion, inability to communicate or the presence of repetitive
Infection of urinary tract 5% motor behaviours, stereotypes and unusual and/or peculiar
Oligohydramnios 1% interests.1,8 Qualitatively, the impairments defining these
conditions are clearly deviant relative to the developmental
Gestation
level or mental age of the individual. All these disorders are
Mean time 39 (31—42)
usually evident from the earliest years of life and can often
Prematurity <37 weeks 20%
be associated with cognitive dysfunction of varying sever-
Type of birth ity. They may also be present accompanying a diverse group
Caesarean section 51% of neurological disorders such as chromosomal abnormali-
Vaginal birth 49% ties, congenital infections and structural abnormalities of
Weight at birth the central nervous system.9,10 All ASDs share some of the
Low weight <2500 g 5% classic symptoms of autism described previously, but they
Normal 66% differ in terms of severity, combination of affected areas,
High weight >3500 g 23% course and prognosis. In RS and DD there is a developmen-
tal regression after a period of normality (5—30 months in RS
Size at birth and 2—10 years in DD). In both disorders, a seemingly normal
Small size <48 cm 11% child loses his/her development in motor skills, language
Normal size 48—52 cm 61% and socialisation, and develops some of the classic symp-
Large size >52 cm 22% toms of autism.11 Although the diagnosis does not require
communication disorders to be present, such impairments
are frequently observed, especially in the pragmatics of
found to be altered and significantly related to the severity language.12 The diagnosis of PDD-NOS is reserved for cases
of the disease (Table 4). that do not exhibit symptoms of autism but do not meet the
When studying the multivariate logistic regression model, criteria for any of the other 4 ASDs because the symptoms
we found a significant explanation for the severity of ASD are minimal or their onset is belated.3
94 C. Talero-Gutiérrez et al.

Table 3 Acquisition age of different developmental milestone.

Developmental milestone Mean Minimum Maximum Late acquisition Not acquired (%)
(months) (months) (months) (months) (%)
Sitting* 7.4 5 24 >9 (11.5)
Crawling 9.4 6 25 >10 (21.8)
Walking 15.1 9 42 >18 (11)
Vocalisation 5.8 2 60
Babbling 10.9 4 163a 2.7
Words 20.7 9 163a >18 (20.8) 4.7
Phrases 42.8 18 163a >24 (33.3) 46.2
a When the developmental milestone had not been reached, we used age of admission to the institution for the calculation of the

mean.
* P < .05.

Table 4 Evaluation of the specific signs of ASD expressed in percentages (%).

Variables ASD sign studied Status of the sign in the patients (%)
Communication Reference to self* Absent 57 3rd person 14 Use of ‘‘I’’ 29
variables Type of communication* Absent 11 Non verbal 46 Verbal 43
Spontaneous speech* Absent 57 Jargon 7 Normal 36
Verbal comprehension* Absent 21 Signs 30 Verbal 49
Acquired linguistic ability Loss of ability 19 Present 81
Behaviour Visual contact Absent 35 Present 65
variables Period of constant attention <5 min 68 >5 min 32
for specific activity*
Imitation* Absent 35 Echolalia 22 Present 43
Use of objects in an activity* Absent 26 1 or > objects 74
Self-care in basic everyday Dependent 76 Independent 24
activities*
Behaviour problems Absent 18 Present 82
Sleep Sleep alteration 21 Normal 79
Socio-emotional Interaction with parents Absent 5 Present 95
development Expression of feelings Absent 7 Present 93
Joint
Attention* Absent 43 Present 57
Play* Absent 7 Manipulative 64 Symbolic 29
* Significant relationship with severity P < .005.

Table 5 Multivariate model used to explain ASD severity.

Variables included in the model P OR 95% CI for OR

Inferior Superior
Diagnosis (autistic disorder) .022 16.159 1.481 176.271
Diagnosis (DD) .015 117.813 2.568 5404.819
Maintained attention (<5 min) .018 3.865 1.267 11.791
Joint attention absent .050 3.089 1.002 9.523
Reference to self absent .021 4.802 1.270 18.153
Self-care .021 5.017 1.277 19.711
Constant .002 0.010
CI: confidence interval; DD: disintegrative disorder; OR: odds ratio; P: statistical significance value.

Some of the difficulties encountered in these children
may be modified with appropriate treatment started early.
For this reason, the American Academy of Paediatrics rec-
ommends close monitoring of all children during the first
2 years, in order to obtain a diagnosis of ASD as quickly as
possible. However, some studies report that the mean age of
identification is around 5.5—6 years. This age is related to
the intellectual level of children, the regression in devel-
opment presented and maternal education, among other
factors.9,11,13,14 The lack of access to specialised medical
Autism spectrum children in Bogotá, Colombia
services and confusion among uninformed physicians delay
an accurate diagnosis. The families of these children are
often given 3 or 4 diagnoses prior to that of autism or
AS.11,13 In addition, diagnostic error is common and gen-
erates high costs for families and service providers. In the
present study, children were identified at a relatively early
age (45 months), but we also observed a significant gap with
respect to the start of treatment (64 months).
We did not find any significant factors in the group of
children studied in this investigation that could be related
to a positive family history or relevant prenatal and perina-
tal problems. The only points that attracted our attention
were, firstly, that half of the population was born by cae-
sarean section, which was significant at a national level,
where the mean figure for caesarean sections in the last 5
years was around 36%.15 This is a predisposing factor consid-
ered by Bilder et al.,10 but in their case it was related more
to the presentation of the foetus than to the surgery itself.
However, we must keep in mind that this type of delivery has
increased significantly in obstetric practice and more so in
the case of higher social strata.16 The second factor was the
figure of premature deliveries. This was slightly higher than
the national average (17%), but was also associated with
the severity of the disorder. As mentioned by Buchmayer,17
the increased risk of ASD in premature infants may pos-
sibly be more related with postnatal problems presented
by these children than with the condition of prematurity
itself.17 The gender difference found in favour of males
(6.5:1) was slightly greater than that reported in the litera-
ture but no explanations can be raised, given the sampling
to our interest employed in this study.18,19
Although advanced maternal and paternal age has also
been associated with the presence of this clinical condition,
in our study group the mean age of parents was 30 and 33
years, respectively.20,21 Moreover, unlike the reports in the
literature regarding the prevalence of psychiatric disorders
in the relatives of the autistic population, the families of
the study group presented no significant psychiatric history
(10%).22
Since Kanner’s original description, which considered
autism as a psychosis of childhood arising from maternal
negligence,1,23 multiple works and approaches have shown
that ASDs consist of neurodevelopmental disorders, primar-
ily of the basic communication skills, development of social
interaction and specific aspects of conduct.10,11,24 Although
in the present study, psychomotor development during the
first year averaged normal, there was a significant percent-
age of children with a delay in motor and language skills
acquisition. The latter were significantly altered, especially
from the second year and, as suggested by some authors,
this could be a predictor of a subsequent diagnosis.25—28 It
is likely that this alteration of language development starts
during the stage of preverbal communication with failures
in the use and recognition of gestures and objects, as well as
the understanding of everyday life situations.21,26 Similarly,
sound production patterns are often abnormal even before
the start of spoken language.27 In general, motor develop-
ment has not represented a compromised aspect in children
with ASD from the point of view of gross skill acquisition,
such as sitting, crawling or walking.24 However, there is a
dysfunction in fine motor skills and coordination that can
be clinically represented by academic learning problems,
95
repetitive movements, mannerisms and stereotypes.22,29
The presence of a delay in the acquisition of sitting in the
children tested may suggest that these children are part of
the group with greatest severity within the overall spectrum.
Regarding the remaining points mentioned, we observed
that all the children presented alterations to greater
or lesser degree in communication, social relations and
behaviour, which was reported as a primary element of diag-
nosis and placement within the spectrum when taking into
account the degree of severity.23
In conclusion, the present study describes the back-
ground and presentation of a selected population of children
with ASD from a reference centre. However, these data
do not allow inferences to the general population. Conse-
quently, a future national collaborative study with children
from different population groups and social strata would
be desirable. In this way, it would be possible to eval-
uate aspects such as incidence, prevalence, risk factors
and aetiology. Finally, mechanisms for early detection could
be proposed favouring feasible and effective intervention
within our environment, in order to minimise the deleterious
effects of this clinical condition.
Financing
This work was supported in part by the Universidad del
Rosario (salaries of researchers and recruitment of young
researchers).
Conflict of interests
The authors have no conflicts of interest to declare.
Acknowledgements
The authors wish to thank Dr. Juan Fernando Muñoz, psychi-
atrist for children and adolescents, for his collaboration in
the initial planning of this work; the medical students from
the School of Medicine and Health Sciences at Universidad
del Rosario Nicole Motta Rojas, Luisa Díaz Galindo, Felipe
Castilla Gómez and Javier Aluja León, for their cooperation
in producing databases; and, finally, Dr. Milciades Ibáñez, for
statistical advice.
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